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    Heart palpitations while lying down, high BP. Vagus nerve irritation? Due to stress?

Posted on Mon, 25 Jun 2012 in Hypertension and Heart Disease
Question: 40yr male. 6 feet, 195lbs. Having heart palpitations while lying down on stomach and both sides, but worse on stomach. Within a few seconds of lying down on stomach, heart rate accelerates. Does not skip beats or have extra beats. It just accelarates the same way as it does w/ anxiety but w/o any conscious anxiety. No symptoms while lying on back. I can also reproduce the same palpitations by simply pressing on an area apprx 4 inches below solar plexus w/ my hand, just above stomach. Vagus nerve irritation? Started about 10 days ago. Visited hospital 3 days ago. ECG, stethoscope exam and blood/urine tests from show everything normal. I was told ECG is "perfect". Blood pressure measured as high as 180/110 at hospital but also as low as 150/93 same day. Not on any medication, and no history of heart problems, just a lot of stress lately.
Answered by Dr. Raja Sekhar Varma 16 hours later
Thank you for your query.

What you are experiencing is an exaggeration of a physiological reflex due to the pressure exerted on the abdomen which is leading to a partial restriction of the movement of the diaphragm and abdomen muscles with respiration and the resultant changes in blood return to the heart and variation in respiration per se.

The higher blood pressure makes the changes in heart rate more obvious to you, since the heart does extra work in pumping blood at a faster speed and against a higher BP. The added difficulty of breathing accentuates your symptoms. This could trigger anxiety too, which worsens things further.

Your blood pressure is above normal (both readings), and you may need drugs to control the pressure. If there is no other contra-indication, a highly specific and long acting beta blocker may be a good choice. Your physician will guide you about the exact preparation and the dosage titration required.

You might also need to get yourself tested for some rarer conditions like pheochromocytoma. A 24 hour urine test for vanillylmandelic acid (VMA)/metanephrines is a reasonable and simple screening test.

I hope this answers your query. Feel free to contact me for any further clarifications.
With regards,
Dr RS Varma

Above answer was peer-reviewed by : Dr. Aparna Kohli
Follow up: Dr. Raja Sekhar Varma 2 hours later
Dear Dr Varma -

First, thank you very much for your answer. I am seeing a PCP tomorrow and will certainly relate what you said. It confirms what I was thinking at least in part. Here's what puzzles me still though:

1. I suspect that the blood pressure has been higher for at least a few months and I have in fact got similar readings at home w/ an instrument (though never 180/110 which was read during a panic attack at the hospital). I've been under tremendous stress at work -- C-level officer at 2 companies and carry a lot of responsibility, and everything has been more and more accelerated and unreasonable, 14 hr days, etc. I'm taking concrete measures to make major and permanent lifestyle changes for better health, including selling one of the businesses, starting to exercise regularly, etc., but need to be well enough to implement these plans and get from point A to B. I've also had physical symptoms of high blood pressure for a few months now -- fluttering of lower eye lids first thing in morning, oversensitivity to anything that's vasoconstrictor -- if I drink 2 beers (which is quite insignificant at my weight) and go to sleep, or the room is especially dry in winter w/ heat on and I'm dehydrated, I wake up w/ heart palpitations -- not of the anxiety kind, not racing, but sort of a cardio zone 3 in exercise terms somewhat faster and definitely _harder_ beating of the heart, like it has to work harder against a restriction. When I walk around and drink lots of water, it usually goes away within minutes. Lately, when I so much as do pushups (we're talking modest resistance exercise that temporarily increases blood pressure -- not benchpressing 300lbs for an hour), the bp and the "flush and full" feeling doesn't appear to come down for hours, sometimes a couple of days, sometimes I have the same palpitation upon waking up the morning after doing pushups. But during this whole time, I was able to sleep on my stomach fine. Why all of a sudden this extreme sensitivity to abdominal pressure in last 10 days, if it's all blood pressure? By the way, in the same 10 days, I've started having panic attacks, and I suspect it's what you said. The anxiety is externally/environmentally driven, and the bp is already there. An external event or anticipation thereof triggers anxiety, the resulting adrenaline constricts veins and makes blood rush faster, which increases pressure more, so I am more aware of the heart, which creates more anxiety, and it spirals down. But I can cognitively control the anxiety from prev. experience and I know it doesn't lead to a heart attack, etc. so I am able to bring it down. This business of hard palpitations of the heart upon abdominal pressure seems to be quite "mechanical" in contrast -- it happens even when I have no conscious anxiety, feeling great and hopeful, or just distracted or engrossed. You press on the area 2-3 inches directly above belly button, everything goes into overdrive and stays that way for a period. That said, I can see the interplay between the mental and physical even in that mechanical process. If I think about it, it gets worse, and lasts longer. If I fear it's a serious medical issue, it gets worse. When you're awakened by discomfort b/c you rolled onto your stomach in your sleep, and it's the middle of the night, it's hard not to think about it. It's worse even now, b/c I'm writing this to you and hence thinking about it.

2. From my own research, I've been concerned about hiatus hernia b/c of the extreme sensitivity to abdominal pressure, what appears to be vagus irritation, and "feeling full" a lot, but I've turned vegan about 6 months ago and have the healthiest diet now. Whole foods, plant based, a lot of raw food smoothies, no animal products, no bad fats, lots of bioavailable protein and carbs, no sugar, no caffeine, etc. So I have a great deal of fiber in the diet, which explains fullness (in addition to the anxiety curbing one's appetite) and no heartburn, regurgitation or any digestive problems of any kind recently, which goes against the idea of hiatus hernia. I also used to be a pretty serious powerlifter, but that was more than a decade ago and I can't imagine I'd have contracted a hernia in my 20s which is only now becoming symptomatic. What are your thoughts on this?

3. Trying to figure out what the _exciting_ cause of this may be, since we're pretty sure about the predisposing cause -- chronic stress, standard American diet and sedentary. I'm pretty sure I'm suffering from "adrenal fatigue" at this point. Not sure if that's even a real diagnosis or just a helpful catch-all term, but the last 2 years have been brutal, and the last few months even more so. So my reaction to setbacks is lower, so is my normally very high energy. This period also has been the most sedentary in my life. So about 6 months ago, I decided to make major life changes. Quit the standard American diet cold, became a vegan. I have no doubt that I'm getting enough and higher quality protein and all the micronutrients. Started standing and walking a lot more, and am constantly losing weight in a healthy, slow way (couple of pounds a month) just by eating more raw vegetables. Never go hungry. I've worked up to being able to walk 10 miles without any fatigue or heart symptoms. So all this should be lowering the blood pressure, if it weren't for the stress and anxiety. The only thing different I can think of that preceded the 10 days of symptoms is that I moved from walking to running the week before. I ran twice in one week, nothing heavy, 3-4 miles each, moderate pace. I used to be a serious athlete so I have very high thresholds for what I consider exercise, but I'm fully aware that one cannot go out there after years of inactivity and redline the machine. I run w/ barefoot form -- that means one wears zero drop shoes (no incline from heel to toe) with almost no soles in order to strengthen feet, legs, joints and balance, and the arms are high up and shoulders back, chest out, shorter strides cycling faster, hips always under legs, forefoot strikes only, heels never touch ground. This is how hunter-gatherers ran for thousands of years, and it's the only way to run long distances w/o causing repetitive stress injuries. The reason this may be relevant is, if not done exactly right (and I'm out of practice), it doesn't allow the diaphragm to come back up all the way during the exhale phase, b/c you always have your shoulders back and arms up w/ forearms parallel to floor and ribs out. Your rib cage is always extended and shoulder blades together. I may have irritated the vagus nerve or the reflex you're talking about. There was no discomfort or palpitations during or after these runs, other than the usual low VO2 XXXXXXX of an out-of-shape person causing him to need more wind, but I noticed an overtraining type palpitation the morning after the 2nd run in 3 days, and then the issue we're talking about started the next day. Could be complete coincidence, but I'm mentioning it in case you think this could have triggered it and/or has bearing on the diagnosis.

- With all this information, do you still stand by your first diagnosis?
- What is that physiological reflex called that you think is being exaggerated?
- Based on the above, would you recommend checking for anything else or any other remedy other than stress reduction and a selective beta blocker?
- Is it safe to _gently_ exercise, maybe just take long walks for now? Should I stay away from jogging and even isometric resistance (like pushups) for a while? It's a chicken-and-egg thing. Exercise is one of the best ways to lower bp, but is my high bp + the abdominal sensitivity condition too much to safely exercise?

Many thanks!
Answered by Dr. Raja Sekhar Varma 44 minutes later
Hello again,
Thanks for the detailed reply.

Yes, I still do stand by my first impression.

I am not aware of a name for this reflex. It is somewhat similar to the strain phase of a Valsalva maneuver (though there are obvious differences too). It is an exaggerated sympathetic system response to the vagal stimuli (from increased intra-abdominal pressure, restriction of diaphragm movement, transient increased venous return and a changed breathing pattern of respiratory muscles from increased use of the thoracic muscles).

Minor changes in heart rate can occur with changes in position, especially when you are relatively dehydrated, anxiety states, etc. Normally, you would not become aware of these changes. Now, with your increased BP, an increased workload on the heart and possibly, the increased thickness (hypertrophy) of the left ventricle, you are increasingly and uncomfortably aware of the changes in rate.

If you have been having higher than normal BP for some time, it is highly likely that the heart muscle has responded by an increase in the left ventricular wall thickness. This can also be seen in athletes. Increase in wall thickness can also happen with weight training and isometric resistance exercises. I would certainly recommend that you reduce such exercises and do more walking, jogging, or swimming.

In view of the high BP, it is necessary to do an ECG, echo of the heart, urine examination for protein, and blood tests for kidney function, electrolytes, blood sugar and lipids. If you need objective documentation of heart rate variations, you could get a Holter monitor for 24 hours. This will also serve to rule out the rare possibility of arrhythmias.

You have only recently started to develop these symptoms. This is partly because the heart muscle takes some time to become hypertrophied as a response to high BP. Also, an increase in your stress levels/ increased anxiety or other similar conditions may be responsible in precipitating these symptoms.

As regards treatment, stress reduction, beta blocker (to control BP as well as to reduce heart rate), and if required anxiolytic drugs may be indicated. It is safe to continue dynamic/aerobic/isotonic exercises.

I hope this clarifies your doubts. I wish you all the best for a happy and healthy life.
With regards,
Dr RS Varma
Above answer was peer-reviewed by : Dr. Yogesh D
Follow up: Dr. Raja Sekhar Varma 1 hour later
Hello Dr Varma -

Thank you again for the quick reply. Just some clarifying info to answer your questions, and a couple of follow-ups.

Here's my clarification. The blood and urine tests were already done last Friday at a big city ER. Kidney and liver function, electrolytes, protein, sugar, lipids all normal. Heart and lungs were listened to by ER doctor as well, normal, w/ good capacity. I can still exhale while counting to almost 100 out loud. So the shortness of breath was determined to be a panic attack -- hyperventilating, too much o2, not enough co2, blow into paper bag, etc. LDL cholesterol 144 (and most likely falling due to new diet), otherwise everything perfect w/ blood. Cell counts good, no anemia, etc. ECG looks good. I think I will get a chest X-ray, and have them do an echo and maybe the Holter for 24 hours. Are there any other tests you'd recommend?

Instead of anxiolytic drugs, I'd like to engage cognitive behavioral therapy and meditation. Benzos are addictive, and SSRI, MOAI, etc. have way too many side effects. I believe I can get the anxiety under control, which is key to self-healing of the body, but the fear of / worry about a present medical condition is making that nearly impossible. If I can only know that there isn't a serious medical condition present or developing, I am 100% positive I can eradicate the anxiety. I have done so before, many years ago. From everything you know so far, how unlikely would you say that this is a serious or life-threatening condition?

1. Does the thickening of the heart wall heal itself when the pressure is down for good, or is that something one has to watch for the rest of one's life once thickened?

2. Is there anything specific that can be done to reduce the abdominal sensitivity / triggering of that reflex? Although I keep losing weight, I still have the distended abdomen b/c I'm "marinating" in cortisol due to the chronic stress. So it physically sticks out still though I'm not overweight anymore by North American standards and moving slowly towards my target weight of 187lbs (85kg at 183cm).
In the meantime, is there anything that can be done (other than tranquilizers, see above), to make the oversensitivity go away? I noticed that if I press there a few too many times intentionally, the palpitation just takes off for hours. So staying off the stomach for a long while letting the beta blockers work certainly seems advisable. But is there anything in terms of drugs, treatment, breathing or other self-help that can be done to specifically and directly address this reflex and this abdominal sensitivity?

3. Related to the above, I have experience w/ breathing in meditation and in exercise physiology contexts. I can regulate the o2/co2 balance (which really helps in a panic attack and which I had forgotten to do till last week), and perform more parasympathetic breathing from diaphragm (as opposed to shallow chest breathing) including breathing into sides and back at will. If a sympathetic reflex is causing this, would it make sense to practice parasympathetic breathing (which relaxes you anyway) as found in some forms of Yoga?

4. Still related to the above, I happen to have professionaly taught exercise in the past including core exercises that can help reduce the distended abdomen, and have helped people with this issue before, including post-pregnancy women. However, the same core exercises that will thin out the belly (both upper and lower) will at least temporarily put a fair amount of pressure into both the thoracic and the abdominal cavities, and hence temporarily also increase blood pressure. We are not talking about situps and crunches which use mostly hip flexors (hence, they don't work). These are hard and very effective exercises that will fire up the rectus abdominus from the solar plexus to the pubic bone and every other core muscle there is around the front, back and sides. I am fit enough still to do the easier versions of these, and have done it once in the last week w/o any adverse effects, i.e. did not appear to trigger the palpitations during, after, or next morning. Is it safe to do these, in addition to the aerobic/isotonic, and if yes, do you think they'll help w/ the condition by reducing the distended abdomen physically?

5. Other than the beta blockers, is there anything I can do to reduce bp? My diet is now v. low in sodium, has enough potassium, no trans or saturated fats to clog arteries, a lot of raw organic foods, a lot of leafy greens and water. Is there anything else diet-wise, supplements, or anything else you'd recommend to lower bp in addition to beta blockers?

6. You did not address the hiatus hernia question. I'm hoping it's because you don't think it applies. Do you think that's simply not possible b/c the diet is so healthy w/ lots of fiber and there's been no acid reflux, regurgitation or digestive issues of any kind? The only thing I can think of is I did have a couple of lenghy upper respiratory infections in the past year with weeks of violent coughing (again, chronic adrenal stress) so I'm concerned I might have pushed the upper part of the stomach through the diaphragm into the thorax. Would that cause the same symptoms in terms of lying on stomach, but if so, would there not also be eating/digestion/hearburn-related symptoms which I don't have? If I'm really hungry and eat too fast while leaning forward, the heart starts going sometimes, but I think that's simply the physical pressure. In fact, I can often alleviate the heart palpitation while standing up by loosening the belt.

Many thanks again!
Answered by Dr. Raja Sekhar Varma 20 hours later

Thank you for the feedback and the queries.

1. Since the blood tests and other tests have been done, Echo, Holter and chest Xray will complete the investigations. If new findings emerge from these tests, they will need to be followed up. Another test that I had suggested in view of heart rate variations, increased blood pressure and panic episodes is to rule out pheochromocytoma with a simple screening test for urine vanillyl mandelic acid (VMA) / metanephrines.

2. Cognitive behavior therapy and meditation are good for reduction of stress and anxiety levels. A short course of a benzodiazepine like alprazolam will not cause addiction. It is very safe and will help you to tide over till the time the non-pharamcological measures start their beneficial effects. You could take them underguidance of your physician and that should be fine.

3. No, I do not think it likely that there is a serious/life threatening condition.

4. Since the high BP has been present for a relatively short duration, there is every chance of reversal of hypertrophy (if present) with effective 24 x 7 BP control. However annual echo is recommended for follow-up.

5. Reduction of stress, control of BP, exercise (as suggested by you), and avoidance of prone positions will all help in avoiding the precipitation of your symptoms. Beta blocker seems to be a good option. I do not recommend any other drugs for this purpose at this juncture. Certainly, breathing exercises, yoga and toning of abdominal muscles will help, as also weight reduction to your ideal weight. You seem to be an expert in physical fitness and very knowledgeable. Therefore, you will be the best judge of how best you can achieve your fitness goals and the specific breathing/exercise regimen that you will need.

6. Yes, it should be safe to do the abdominal exercises provided you take some care in the performance, be regular and avoid overdoing things. Reduction of an over distended abdomen will help, but remember that it is only one of the parameters.

7. I think your diet as described is fine. You could add some fruits too, in addition to the vegetables. I am not a fan of supplements. A healthy and nutritious diet is better than expensive food supplements. I do think that diet, exercise and a single drug should be enough at this stage. If the BP is not optimally controlled despite a good dose of the drug even after 3 months, you could add a second drug, preferably an ACE inhibitor.

8. You are right. I do not really think that a hiatus hernia is likely without any other corroborative evidence. If you are really concerned, an upper GI endoscopy or a barium swallow should help to diagnose it. However, it is less likely and I am not keen on advising (unnecessary) investigations.

I hope I have been able to answer all your queries. Please accept my answer if there are no further doubts.

With regards,
Dr RS Varma

Above answer was peer-reviewed by : Dr. Prasad
Follow up: Dr. Raja Sekhar Varma 48 minutes later
Hello Dr. Varma -

Very quick last question: so it's quite possible that I could have this extreme sensitivity in the abdomen, inability to lie on stomach/sides w/o heart palpitations, etc. for 2 weeks+ for no other reason than the high BP and the reflex you mentioned -- without there being a tumor or hiatus hernia or anything else inside the cavity creating the extra pressure? That reflex can continue for weeks and months unless/until I lower the BP? This should be the final question. Thanks again!
Answered by Dr. Raja Sekhar Varma 58 minutes later
Thanks again.

Yes, I would consider that as a most plausible explanation taking into account all the factors that you have given and without the luxury of a physical examination - exaggerated reflex, high BP, stress and anxiety.

If you are worried about abdominal problems you could get a screening done with an endoscopy, ultrasound scanning of the abdomen and the special urine test that I had indicated earlier. Among these the urine test is one that I would recommend and keep the others optional. If there is no response to the treatment measures, you can go for more detailed tests to diagnose rare causes.

I would appreciate it if you can keep me updated with your progress.
With regards
Dr RS Varma
Above answer was peer-reviewed by : Dr. Yogesh D
Answered by
Dr. Raja Sekhar Varma

Cardiologist, Interventional

Practicing since :1996

Answered : 192 Questions


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